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Sun Sep 13 17:06:59 BST 2009

A clamshell to repair an esophageal injury is a special nightmare and  
horrible experience, at least for me.   For esophageal injuries  repaired via an 
anterior incision there is a 50% breakdown and among those there  is a 50% 
mortality from sepsis.   

Thank goodness you did not use rFVIIa.   I am also increasingly  becoming 
concerned that this product has very very little if any application in  the 
trauma patient.  

k

In a message dated 9/12/2009 1:43:35 P.M. Central Daylight Time,  
moore677 at aol.com writes:

Two patients arrived with GSW's, first with GSW L  shoulder to L chest 
(didn't require chest tube though) and second with GSW L  shoulder, through L 
chest, mediastinum, lodging in R chest.? Hypotensive,  placed 2 left chest 
tubes (first failed to evacuate HTX) and one left chest  tube, MTP protocol 
initiated.? Prepping chest for ED thoracotomy as pressure  initially in 40's, 
but responded to blood products.? Managed to resusc to get  CT scan which 
showed persistent large L HTX despite 2 chest tubes, ? esophag  injury, ? L SCL 
artery injury.? CT's initially out about 1000, with second  tube 200, and 
by finishing?CAT scan?about 1800-2000.? ? intra-abd injury on  CT.

Would any of you went straight to OR without CT knowing  this could provide 
invaluable information regarding trajectory (great vessel  injury, etc.)?

?

In OR, started with L anterolateral thoracotomy  to explore L chest for 
massive HTX.? Multiple injuries to LUL and LLL but  didn't require anything, 
obvious injury to esophagus at T2/T3 level.? Bronch  clean, EGD shows possibly 
2 full thickness injuries.? 

Would  any of you extend the?L thoracotomy to a clamshell or do a?R 
posterolateral  thoracotomy?? 

We examined L diaphragm and didn't identify any  breaches/injury and EGD 
didn't reveal any gastric injury so did not pursue  exlap (CT with ? fragments 
below diaphragm, possibly anterior to stomach).?  Patient very stable with 
resuscitation (used 1:1:1), no  FVIIA.

Dell..............

Forrest "Dell"  Moore, MD, FACS

Director, Trauma/Surgical Critical Care

St.  Joseph's Hospital and Medical Center

Phoenix,  AZ

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TRANSMEDIASTINAL GSW